Please indicate N/A if not

applicable. Do not leave

unanswered spaces. TY.
2x2
ID PICTURE
RECENT
Applying for Rehab process as? ____ _____ (FTMW / KMM - Kingdom Miracle Member) (Formal)

Complete Name of Rehab Applicant_____________________________________

(First name / Middle Name / Last Name)

Birthdate: _____________ __ Birthplace: ________________ ____

Age: ________ Gender: ________ ___ Civil Status: ______ ______

Present Address: ____________________________________________________________________

Email Address: ________________________ ___ Contact No/s.________________________________
Educational Attainment: _________________ ______ School/University:
__________________________

Employment History: _______________________________ Years/Mos. Employed____________

Company/Designation (if employed at present): ____________________________________________
If unemployed, what are the ways/means to earn a living? __monthly allowance sent by my boyfriend__
___________________________________________________________________________________

(Please specify their SPIRITUAL STATUS: Ex-FMTW / FTMW / Former Member / Member / Unbeliever)

Name of Spouse: ___________________________ Spiritual Status: ____________________

Number of Children: ___________________ (Please specify names, age/s and status of children)
1. _______________________ Age: ___________ Spiritual Status: _________________

2. _______________________ Age: ___________ Spiritual Status: _________________

3. _______________________ Age: ___________ Spiritual Status: _________________

4. _______________________ Age: ___________ Spiritual Status: _________________

5. _______________________ Age: ___________ Spiritual Status: _________________

Mother’s Name: ______________________ ___ Spiritual Status: ______________________ _

Father’s Name: _______________________ ___ Spiritual Status: _________________________

Date/Year Baptized: _____________ _ under _________________Name of Coordinator: _______________ __

Date/Year Re-baptized: ________ under KLC of ______________ Name of Coordinator: ___________________
Date/Year Entered as FTMW: ___________________ ___ KLC Origin: _______________{_ ________

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Date/Year became Inactive/Backslide: _________________ EX-FTMW? ___ FORMER MEMBER? ___
Date of Being Suspended - with memorandum number: _______________________________________
Ministry History (Please specify Year/Date and Ministry and Department Assigned):
1. _____________________________
2. _________________________ ____
3. ______________________ _______
4. _____________________________
5. _____________________________

Medical History (Please specify if undergoing medication)

1. _______________________________________________________________
2. ________________________________________________________________

Are you taking maintenance? Yes ______ No ________ If Yes, please specify:
____________________________________________________________________________

Reason of being In-active/Backslider/Suspended from the Kingdom:

____________________________________________________________________________

Life outside the Kingdom (Write in detail)

____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

Efforts in listening to the messages of the Appointed Son and what have you understood.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

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Letter of Appeal (You may extend/continue if space is not enough):
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

In the King Service,

Applicant’s name with Signature

Noted by:

____________________ ____________________
Coordinator Minister

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